BC Advantage

DECISION SUPPORT SYSTEMS: Medicare Imaging Demonstration Project to Study - July, 2011
In case you haven't yet heard, the Centers for Medicare & Medicaid Services (CMS) will launch a Medicare imaging demonstration (MID) project in July to study appropriate utilization of advanced imaging services. The demonstration includes only those services provided to Medicare fee-for-service beneficiaries paid under Part B (hospitals and outpatient clinics). Inpatient (Part A) and emergency department imaging services are excluded.
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Place of Service Codes: Get Them Right to Ensure Compliance - April, 2011
One of the projects included in the Department of Human Services' Office of Inspector General's (OIG) 2011 work plan is a review of claims for proper place-of-service (POS) coding for physician services. These two-digit POS codes are placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.
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OIG Issues 2011 Work Plan: Several Radiology-Related Audits Planned - February, 2011
Each year about this time, the Department of Health and Human Services' Office of Inspector General (OIG) launches its general work plan for the next calendar year. For 2011, the OIG has seven audits (called "areas of investigation" in the report) scheduled for providers who deliver radiology services to Medicare Parts A and B beneficiaries. Of the projects announced, three of these are "new starts" and four are what the OIG calls "works in progress." In other words, if you're aware of the OIG's work plans from previous years, the works in progress below will sound familiar.
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When using a thrombectomy catheter during percutaneous cardiac intervention (PCI), can 92973 be assigned when a manual extraction catheter such as the Pronto or Quick-Cat is used? - November, 2010

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Financial Impact of Lab Audit Findings: Dig Deep to Uncover Reasons for Claim Denials - November, 2010
In the course of performing a laboratory billing audit, I observed that a charge for an alkaline phosphatase (CPT 84075) sometimes appeared on the same claim with a charge for a comprehensive metabolic panel, CPT 80053. Given that the alkaline phosphatase (alk phos) is one of the components of the comprehensive metabolic panel (CMP), the facility received a line item rejection of the alk phos and no additional money for the procedure. This finding raised several questions that begged asking.
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Anti-Markup Payment Limitations: CMS Issues Instructions for Policy Compliance - May, 2010
In two recent transmittals, the Centers for Medicare and Medicaid Services (CMS) advise physicians and other suppliers who bill for diagnostic tests (excluding clinical diagnostic laboratory tests) to understand when the anti-markup limitation applies and when it doesn't.
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Under the RAC Microscope: Medical Necessity of Services - March, 2010
When it comes to recovery audit contractors (RACs), hospital leaders continue to ask: Where should we focus our time and attention? The answer is medical necessity-a key RAC target.
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Proposed 2010 Hospital OPPS Rule Issued: Many Changes Included, Some Welcomed - November, 2009
As you may know by now, the Centers for Medicare & Medicaid Services (CMS) have issued the proposed rules for 2010. One of the rules contains updated payment policy and rates for the hospital outpatient prospective payment system (OPPS) as well as ambulatory surgical centers (ASCs). The other rule updates the Medicare physician fee schedule (MPFS). Whatever elements of the proposed rules become final will take effect on January 1, 2010.
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New ICD-10-CM Coding System: CMS Sets Date for Implementation - July, 2009
Just six months after it issued a proposed rule for adopting the ICD-10-CM code sets, the U.S. Department of Health and Human Services (HHS) issued two final rules related to the topic. This is surely record time for the agency, indicating that its leaders are definitely listening to the likes of industry associations such as the American Hospital Association (AHA) and the American Health Information Management Association (AHIMA).
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2009 Coverage for Telehealth Technology: More Reimbursable Services and Eligible Sites - May, 2009
Radiology is among the medical specialties that most frequently use telehealth technology. The 2009 Medicare physician fee schedule (MPFS) adopts a couple of provisions of interest to those radiology practices now offering, or may offer in the offer, these services.
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BE PREPARED FOR MAC TRANSITION: Tips to Minimize Billing Disruption - March, 2009
By now, you've heard of Medicare administrative contractors (MACs)-firms that are taking over the responsibility of Medicare claims processing from fiscal intermediaries (FIs) and carriers. The Centers for Medicare & Medicaid Services (CMS) has already awarded MAC contracts to 10 of the country's 15 jurisdictions, and providers in many of these jurisdictions have claims systems up and running with their new MACs. For those providers who have yet to participate in the MAC program, the CMS recently issued instructions to help smooth the transition.
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More Bundled Medicare Payments Ahead: ACE Demonstration Tests Concept for Acute Care - September, 2008
With the recent announcement of the Acute Care Episode (ACE) Demonstration, the Centers for Medicare & Medicaid Services (CMS) sent a signal to the industry that it intends to head in the direction of bundled payments for inpatient physician and hospital services, at least for select procedures. The ACE Demonstration will test whether the new payment structure results in cost efficiencies and quality improvements for Medicare and its beneficiaries.
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Physician Signatures on Test Requisitions: CMS Clarifies Medicare Policy - July, 2008
Has your laboratory received documentation requests from the comprehensive error rate testing (CERT) contractor (AdvanceMed) asking for an original requisition signed by the ordering physician? If so, you're not alone. According to a letter from the American Clinical Laboratory Association (ACLA) to the Centers for Medicare & Medicaid Services (CMS) in mid-March, many laboratories have received such requests. What's more they received notification that the testing is inappropriate, and the claim will be denied if no such requisition can be produced. (Don't panic! It's not true.)
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Codes Subject to CLIA Edits in 2008: CMS Issues a List of Eight Codes - July, 2008
As you probably know, the CPT codes that CMS considers to be laboratory tests under CLIA, which require a certification, change each year. In Transmittal 1471 (February 29), CMS informed Medicare carriers and Part A/B Medicare administrative contractors (MACS) about the 2008 codes that are subject to CLIA edits and also about those that are now excluded from CLIA edits.
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Billing Emend® Tri-Pak on Outpatient Claims: Clarifications Issued on Wrongful Denials - May, 2008
It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that payment denials are occurring for the three-drug combination of oral anti-emetics contained in the Emend Tri-Pak because two doses of anti-emetics are sent home with the patient. The denial of these claims resulted from a misinterpretation by the Medicare fiscal intermediaries (FIs) of a policy concerning the billing of take-home drugs.
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Ordering Diagnostic Tests in Non-Hospital Settings: CMS Discovers and Issues Missing Guidelines - March, 2008
Although it's been several years since the Centers for Medicare & Medicaid Services (CMS) transitioned from the Medicare Carriers Manual (MCM) to the Internet-only manual, it has just gotten around to incorporating language it says it "inadvertently omitted" related to the requirements for ordering, and following orders for, diagnostic tests in non-hospital settings.
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Final 2008 Hospital OPPS Rules Issued: Details for Pharmacy Departments Abound - January, 2008
The 2008 interim and final rule with comment period for the Medicare hospital outpatient prospective payment system (OPPS) weighs in at 1,969 pages! As you might imagine, it is chock full of changes to implement new statutory requirements and refine various parts of the payment system. All changes, unless otherwise noted, take effect on January 1, 2008.
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Laboratory and Pathology Claims: Top Denial Reasons from Trailblazer - January, 2008
Duplicate claims' submissions are the number one reason for denials or rejections of laboratory and pathology claims, according to Trailblazer Health Enterprises, a Medicare contractor.
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2008 MPFS Final Rule Highlights Lab Changes: DOS for TC of Pathology and Reconsideration Process - December, 2007
The 2008 final Medicare physician fee schedule (MPFS) includes two sections related to the clinical laboratory fee schedule. More details about the new policies can be found in the MFPS sections noted.
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Reconstruction of Computed Tomography: ACR Issues New Opinion on Initial Data Studies - November, 2007
The American College of Radiology (ACR) recently published information about the reconstruction of computed tomography (CT) studies from initial data. Its previous opinion and new opinion are provided below. A follow-up question from MedLearn to the ACR is also provided as well as a response to it from an association representative. A brief analysis by one of the situation caused by the new ACR opinion concludes this article.
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